Journal
AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY
Volume 27, Issue 12, Pages 1316-1330Publisher
ELSEVIER SCIENCE INC
DOI: 10.1016/j.jagp.2019.07.016
Keywords
Depression; depressive disorder; relapse; recurrence; homeostasis; geriatric; default mode network; remission; remitted; stress; executive control network; allostatic load; cognition; aging; risk factors; review
Categories
Funding
- National Institute of Mental Health [R01 MH076079, R01 MH102246, R01 MH108509, R01 GM113243, K24 MH110598]
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The significant public health burden associated with late-life depression (LLD) is magnified by the high rates of recurrence. In this manuscript, we review what is known about recurrence risk factors, conceptualize recurrence within a model of homeostatic disequilibrium, and discuss the potential significance and challenges of new research into LLD recurrence. The proposed model is anchored in the allostatic load theory of stress. We review the allostatic response characterized by neural changes in network function and connectivity and physiologic changes in the hypothalamic-pituitary-adrenal axis, autonomic nervous system, immune system, and circadian rhythm. We discuss the role of neural networks' instability following treatment response as a source of downstream disequilibrium, triggering and/or amplifying abnormal stress response, cognitive dysfunction and behavioral changes, ultimately precipitating a full-blown recurrent episode of depression. We propose strategies to identify and capture early change points that signal recurrence risk through mobile technology to collect ecologically measured symptoms, accompanied by automated algorithms that monitor for state shifts (persistent worsening) and variance shifts (increased variability) relative to a patient's baseline. Identifying such change points in relevant sensor data could potentially provide an automated tool that could alert clinicians to at-risk individuals or relevant symptom changes even in a large practice.
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